Integration of EPIT into a meta-model of interprofessional development

7.3 Integration of EPIT into a meta-model of interprofessional development

A professional identity with an interprofessional orientation is important for enhancing interprofessional collaboration; however, it is only one component of professional competence.

It is a meta-competence that influences priorities and actions (Harrington & Hall, 2007).

Thus, professional identity does not include competences with regard to discipline specific expertise, knowledge of other disciplines, or collaborative skills and procedures. Professional identity guides priorities and actions built on the available attitudes, knowledge, and skills that are required to function as a professional in a work related context. In order to fully comprehend the requirements that an individual needs for interprofesional collaboration, a model is needed to guide the development of a professional with his or her own expertise and uniprofessional identity as a starting point.

Many models and theories concerning interprofessional collaboration describe the competencies, characteristics, desired outcomes, or conditions that are required for interprofessional collaboration (e.g., Anderson & Lennox, 2009; Barr, 1998; WHO Working Group, 2010; Vyt, 2009). However, these models do not provide a practical incremental approach to interprofessional development. Furthermore, these types of models are also criticized for lacking ‘conceptual clarity’ (Carpenter & Dickinson, 2008). A recent model, DPIIM (Dual Professional and Interprofessional Identity Model), predicts that a combination of team and professional commitment will enhance interprofessional collaboration (Khalili et al., 2013). A study confirms the predictions of the DPIIM (Caricati et al., 2015). However, the DPIIM is a predictive model with general developmental phases for identity formation and is not an intervention model nor is it related to interprofessional development in general. The extended professional identity theory is meant to be an intervention theory and also does not include all of the requirements for interprofessional development. Therefore, this theory should be an element of an overarching model to clarify developmental steps. Therefore, a new model is proposed: a meta-model of interprofessional development. The purpose of this meta-model is to provide specific priorities for curriculum and team development beginning with an encounter between individuals with uniprofessional identities. An intrinsic motivated individual with an extended professional identity is the final phase of interprofessional development. In this context, both the extended professional identity theory and the meta-model of interprofessional development are complementary to the work of Khalili et al. (2013) and a logical follow up.

The meta-model of interprofessional development consists of several conditional requirements (phases) for interprofessional development numbered from 0 to 5 (Fig. 2). Each phase is semi-conditional to the next phase, has an increasing complexity because of a cumulative nature, and moves towards an increasing interprofessional self-regulation (intrinsically motivated interprofessionality). Even though phases are (semi-) conditional, they can overlap

and occur in a short amount of time, i.e., a couple of hours. However, investing more time in each phase will result in a more comprehensive development during a phase. The first three phases concern an orientation without connecting fields of expertise. The phases after these first three concern an instrumental and rational approach to connecting different fields of expertise ending with internal motivation to connect more than one expertise.

Figure 2.

Meta-model of interprofessional development

Phase 0 is a non-work related social orientation or acquaintance and will lead to a connection on a personal level but is not related to occupations or professional positions. Becoming familiar with someone will emphasize unique individual characteristics and make professional characteristics less prominent (Brewis, 2008). The outcome of this phase includes attitudes towards a specific person.

During Phase 1, the professional capacity emerges and the acquaintance will usually occur in a work related context. In contrast to personality, social identities are contextual and moderately stable (Ginsburg et al., 2003). Each context can trigger another social identity or several of them. Thus, context will activate a corresponding social identity or role identity which will

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subsequently guide corresponding behavior. However, before this professional acquaintance takes place, occupational stereotypes can influence ingroup-outgroup behaviors and selective perceptions (Tajfel & Turner, 1979). Intergroup contact can dispel such stereotypes (Allport, 1954) which is why facilitating personal contact between members of different professions is one of the most popular strategies applied in interprofessional education (e.g., Carpenter &

Dickinson, 2016; Khalili et al., 2013; Mohaupt et al., 2012; Hean & Dickinson, 2005). However, according to the proposed extended professional identity theory, mere intergroup contact between members of different professions will not enhance interprofessional commitment but only increase positive attitudes and interprofessional tolerance. The study of Chapter 5 provides some evidence for this assertion. Interprofessional contact in ‘isolated’ mixed profession groups will not change the relative professional positioning between different professions, and social commitment will remain uniprofessional.

In Phase 2, the professional orientation can become more comprehensive and the scope of practice and profession specific expertise can become clearer. This phase is conditional for the next phase since knowledge of professional roles makes it possible to assess the added value of a certain profession for patient centered care (Macdonald et al., 2010). Lack of knowledge regarding role or scope of practice can also contribute to assumptions regarding occupational competence or lack thereof when evaluating other professions. Therefore, orientation on professional content or other’s scope of practice can also contribute to the discrediting of occupational stereotypes (Allport, 1954). Once professionals have a relatively clear view on the added value of other fields of expertise, interprofessional connections can be made.

Phase 3 consists of interprofessional procedures that facilitate interprofessional connections.

This concerns information sharing, shared (clinical) consultation and decision-making, and shared care planning and evaluation. Therefore, skills related to team building and interprofessional collaboration are also inherent in this developmental phase. Shared procedures are the instrumental foundation of interprofessional collaboration. However, innovations are needed; new strategies must be developed to enable integrated care (Kodner

& Spreeuwenberg, 2002; Stange, 2009). Thus far, the conventional health care system is especially focused on the coordination of different care paths by one leading profession instead of integrated connections between several professionals in a single care path (Stange, 2009).

This is also the essential difference between multi- and interprofessional collaboration (Fig.

3). Even though these two concepts are often confused (Perreault & Careau, 2012), they are distinct constructs. Multiprofessional collaboration is more directed towards delegation from one (leading) profession to another and only concerns the involvement of different health professions. Interprofessional collaboration is directed towards concertation between health professions and concerns collaboration between health professions (Bachmann, Kiessling, Härtl & Haak, 2016).

Figure 3. Multiprofessional versus interprofessional collaboration

Thus, multiprofessional collaboration leads to the coordination of separate ‘production lines’

per patient each of which is the domain of a specific discipline with its own distinct goals. This way, the care of one patient becomes fragmented (Kodner & Spreeuwenberg, 2002; Stange, 2009). Interprofessional collaboration emphasizes content related connections (concertation) between different fields of expertise. Naturally, this applies to the entire integrated care path of each patient whereby the patient routing begins with the point of entry. This also means that even the necessity of involving a certain discipline in a care process cannot be determined by just one profession. More than one profession should be able the be a point of entry to the health care system as long as they are competent and authorized to do so.

Macey, Glenny, and Brocklehurst (2016) provide evidence that collaboration between dentists and dental hygienists can be advantageous to patients when dental hygienists also perform check-ups. This way, the health care system can be organized more efficiently. In this case, the responsibility for integrated care is the responsibility of any recognized profession. To address complex and multi-facet care problems, not one single discipline or professional can possess all of the knowledge needed to comprehensively shape an integrated care path of a specific and unique patient. Thus, delegation based on general assumptions about the expertise of

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another discipline is, generally, not interprofessional but multiprofessional and can reduce quality of care. Even more so, fragmented care poses a threat to patient safety. Therefore, interprofessional collaboration is also perceived to be a way to enhance patient safety (Thistlethwaite, 2012; Tjia et al., 2009). The organizational structure of health care and the way professionals are trained mutually affect each other (Long, 2013) and sustain a fragmented care approach as long as these interacting factors mutually reinforce each other. This is the reason that new methods of working and training are required if we want to overcome the rising costs and future challenges of health care.

Phase 4 concerns the environment in which collaborative action takes place. Collaborative procedures can be obstructed or enabled by environmental factors. Thus, collaborative procedures, as part of the clinical and professional context, are imbedded in organizational and systemic environments. These environments play an important role in behavioral guidance and professional socialization. This distinction of different levels in the health care system are confirmed and described by several models: Person-centered Practice Framework (McCormack & McCance, 2011), The Bellagio Model (Schlette, Lisac, Wagner

& Gensichen,2009), Rainbow Model of Integrated Care (Valentijn, Schepman, Opheij &

Bruijnzeels, 2013), and Development Model for Integrated Care (Minkman, 2012). This distinction helps us to understand the impact of the organizational and systemic environment on interprofessional collaboration in both educational and work settings. In the educational setting, the organizational and systemic factors are represented by influences of the ‘hidden curriculum’. A hidden curriculum is a side effect of education that becomes visible in learned but unintended transmission of norms, values, and beliefs conveyed in the educational environment (Henry & Anthony, 1979). It reinforces existing social inequalities by educating students according to social position (Apple & King, 1983). Another educational influence is the impact of reward and feedback methods on individual and collective behavior. Simular to the hidden curriculum are the influences of organizational culture on relationships and communication between co-workers. In the work setting, organizational reward and feedback methods are not the only influence on the work climate. The organization itself must operate in an even larger and more complex system in which politics and policies, laws and regulations, and health insurance and remuneration methods impact work behaviors and professional priorities.

Phase 5 concerns the internalization of interprofessional belonging, interprofessional beliefs, and interprofessional commitment as a component of the professional identity. This is not the result of extrinsic motivators that derive from environmental influences but concerns an intrinsic motivation to work with other professionals and utilize more than just an individual’s own field of expertise. This way, interprofessional commitment can guarantee interprofessional self-regulation without the need for continuous external reinforcement. In this phase, interprofessionality is internalized and becomes a natural element of a person’s

professional identity and the professional competencies that are guided by this identity.